5300 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 10 NTI FICATION
AD Ss APPLICATION & PERMIT PERMIT NUM6ER
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 5300
OWNER'S
NAME
k��,(,.L. 5a{{ //aa ::maT�yy %[�' PLAN CNECK VALIOATI ON
• PHONE HI'.T-4v a.... - a�M�na~'�ryS "ATfa?WY"
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
CONTRACTOR 'JC 7
Clc.No. LIGHTING FIXTURES 5.00/100 APR - 3 1984
AOGFEss PPLIANCES-RESIDENTIAL 4,00
ORCHIT CT
PHONE PANELS a/(�J�k 5-DD VEQfF Ia
//11
OR `�
ENGINEER —_ SIGNS 6.00 PLAN CHECK FEE C.NO.
ARC"
.Op ELIC.NO. SIGNS TRANS. 300
NG. '
AGDRFSS SPECIAL CIRCUIT
-- 5.00 PERMIT VALID TION
APPLI ANTS ZIP EMP.METER OR POLE INS. 15.00
AOOpEss gaf(f2 MOTORS
SEE FEE SCH.
o ¢ i SERVICE CHANGE 10,00
.00 LICENSED CONTRACTORS DECLARATION
ri w 1 hereby affirm that 1 am licensed under provisions of Chapter
se a (commencing with Section 7000)of Division 3 of the Business and
F 0 z Professions Code d Nicest if in full force a ISSUANCE DATE
2
2 n 0. License Chs I.K.Number G� BL ELECT. PLn.6
H w Date 76•M= 4�LComosetor 19 O
4Kf
¢ w OWNER-BUILDER DECLARATION
w0a
3 1 hereby affirm that 1 am exempt from the Contractors License MISC.— REFER TO ORD
H :o Law for the following reason,(Sec.7031.5,Businessand Professions
Code:Any city or county whichrequiresa permittocamtrucl alter, PERM 4T ISSUANCE VALUATION S/FT.
¢ ¢0 G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. 6-�
e. w m o requires the aPPlicanl for such permit to file a signed statement that LIC.NO.
he is licensed pursuant to the provisions of the Contractors License ELEC.
F. > Law(Chapter 9 TOTAL '
zQ P (commenCode)-1 Section is exempttheronlofthe - PERMIT TO
Business and he alleged
a Code)or[hal he is exempt Therefrom and
a the basis for the alleged exemp0on,Any violation of$ection 7031.5 1
a 3 _ by any applicant for a permit subjects the applicant to acivil penally STORIES
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT•WATER (EA.14.00 ryre CONSTR.
❑ 1,as owner of the properly,or my employees with wages as
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT. DEVICE
intended or offered for sale(Sec. 7004, Business and Professions 200OCC.GROUP RES.UNITS
Code:The Contractor's License Law does not apply to an owner of DRAINS-FLOOR,ROOF,AREA,COND. 4.00
property who builds or improves thereon,and who don such work
himself or through his own employees,provided that such improve- FIXTURES-PER TRAP q
• menti are not intended or offered for sale,If,however.the building GAS-EA.SYSTEM-11NC.4 OUTLETS. .00
4.00 M Fr.FLOOR AREA TOTAL ACREAGE
or improvement is said within one year of completion, the owner-
buildcr will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.)
prove for Purpose of sale.). 1.00 BUILDING USE
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. ES IND CON PR Ochar
licensed contractors to construct the project ISec. 7044 �'� ❑ ❑
and Professions Code:The Con tractor's License Law does not apply LAWN SPRINKLERS-11NC5 V.B.
to an owner of Property who builds or improves thereon,and who 6'00 ASSESSORS PARCEL NO.
contracts for such projects with a contmctor(s)licensed pursuant to LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00
❑ 1 am exempt under Sec. .B.&P.C.for this TRACT NO. PARCEL NO.
reason ensu WATEH HEATER W/VENT
Owner I 4.00
Date WATER SYSTEM
WORK I:RS'COMPENSATION DECLARATION 4'� ACC.DATE ACC.FILE NO.
I hereby affirm that 1 have a certificate of consent to self-insure, WATER TREATING EQUIP, 4.00
or a cenlfi"cJ.c I,I, Vol ers'Compensation Insurance,or a certified
c pI e I "L 800,Lab.C.l.i 1 ZONING ENG.SITE NO.
N+V Company /ll��
0 ❑ Certified 'OPy Is by( s
Z ❑ Cenif py filo '��,
O APPlicant ` C�z�f7�Ew ion division.
A'1150•- FIRESPRINK ENERGY T 24
REFER TO ORD. Y❑ N❑ Y❑
LU
CERTIFICATECOMPENSATION
INS FROM WORKERS' PERMIT ISSUANCE N❑
LU COMPENSATION INSURANCE 6.00
d O _ PLG.CONTR, LIC.NO. FLOOD ZONE A.L.U.C.
his section need not be comp6ted i(the permit u for one PLO. ,sem
UO huI cenifu lhatn1 the less.) TOTAL f�`'' y�
1 certify that h the performance of the work for which thii per- I
0 F mit is issued,1 shall not employ any person in any manner
L become suhject to the Worken'Compensation Laws of California.
Q. Dale Applicant -
} w NOTICE 'r0 APPLICANT: If after making this Cenifscate of Ex- ALTER OR ADD TO MECH. BUILDING
F- Z emption,you should become subject to the Worken'Compensation 4,00
U suchlprovisionsthe
or thispermo shay be de, you mostdeemforthwith
comply with APPLIANCE 4.00 PLAN CHECK
AIR HANDLING UNIT(TO 10m0C.F.IM 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10
I hereby affirm that there is i construction lending agency 6'00 SEISMIC FEE
the Performance of the work for which this S agency for EXHAUST HOOD(WITH DUCT) r
3097,Civ,C.), permit is issued(See 2.00
Lender's Name HEATING UNIT(TO 100,000 B.T.U.) - 4.00 MICROFILM
Lender's Address
I HEATING UNIT(OVER 100,000 B.T.U.17.50
certify that I have read this application and state that the above ELECTRIC
• information is correct. I agree to comply with all city and county VENTILATION FAN (SINGLE) 3,00
ordinances and state laws relating to building construction, and BOILER•COMa PLUMBING �1 U
hereby authorize represenhtives of this city to enter upon the (3 H.P.Or 100,000 B.T.U.) 4.00
above-mernioned Property for inspection purposes. BOILER-COMP (Owl 100,
(We) agree to save, indemnify000 BTU)SEE FE E SCH. MECHANICAL
Cupertino against liabilities judgments and keep harmless the City of MISC.- REFER TO ORD.
1 tments, costs and expenses which
may in any way ecru ainat said City in consequence of the PERMIT ISSUANCE
grant' ft is il. 3-00 CONST.TAX
MECH.CONT. LIC.NO, TNEC 4.OTAL sUf`A
oo re Applicant) antra Date I 06
r OFFICE COPY